Managing the side effects of ibrutinib treatment 

This review aimed to discuss the toxicities of ibrutinib (Imbruvica) treatment and how to manage them. This review concluded that patients should be regularly monitored for toxicities and actively treated to reduce side effects and avoid disruption to treatment.

Ibrutinib is a type of targeted therapy known as a Bruton tyrosine kinase inhibitor (bTKI). It works by blocking the signals that help cancer cells to grow and divide. It has become the standard treatment for patients with chronic lymphocytic leukemia (CLL) or some types of non-Hodgkin lymphoma (NHL). Treatment with ibrutinib is indefinite so toxicity (side effects) and long-term tolerance of the drug are important. 

This review discusses ibrutinib side effects and their management.

Data from previous studies indicate that stopping ibrutinib treatment occurs in up to 51% of patients after 5 years. The majority of this 51% was due to side effects.  

Atrial fibrillation (AF; abnormal heart rhythm) is a side effect of ibrutinib. It can happen in up to 30% of patients during 10 years. Managing this side effect is complicated and involves collaboration with a cardiologist. However, ibrutinib can be stopped and restarted once a regular heart rhythm is regained.  

Bleeding and major hemorrhage are known side effects of ibrutinib. Emergency or elective surgery can be used in the management of this side effect. A platelet (blood cells involved in clotting) transfusion can be considered even in patients with normal platelet counts. Patients that also receive anticoagulant or antiplatelet medications should be carefully managed.

Hypertension (high blood pressure) is another commonly reported side effect. It has been reported in up to 17% of patients over an average of 30 months. Antihypertensive drugs can be used to manage hypertension and there is no need to reduce the ibrutinib dose.

Joint and muscle pain can also be ibrutinib-related toxicities. Management includes painkillers and corticosteroids if required. Fatigue can be experienced, usually in the first 3 months and in older individuals. Unless severe, dose reduction of ibrutinib is not recommended.

Infections have been commonly associated with ibrutinib treatment. Urinary and respiratory infections (including pneumonia) were the most commonly reported. Reactivation of the varicella-zoster (shingles) or hepatitis B virus have also been reported. Stopping ibrutinib is recommended in severe infections until clinical improvements are seen. Anti-infective therapy should be given according to resistance patterns.

Skin and nail effects (such as rashes) can occur in up to 27% of cases but often resolve themselves. Management, if required, involves corticosteroids. Other toxicities include diarrhea, lymphocytosis (high number of white blood cells), and cytopenia (low in blood cell counts). Stimulating medications can be given in such cases.

This review concluded that patients treated with ibrutinib should be regularly monitored for toxicities and proactively treated to reduce side effects and avoid disruption to treatment.